The first reported HIV outbreak in a British prison, at Glenochil,1 is an alarming but not at all unpredicted event.2 Unfortunate, from the point of view of the national public health, is that prisoners do not stay in prison indefinitely - the uncontrolled spread of HIV infection between prisoners threatens the government's successful HIV control programme and presents a grave threat to the nation's health.

In this outbreak the coincident presentation of jaundice due to hepatitis B led to the recognition of HIV infection. We have no direct knowledge of conditions in Glenochil and make no comment on the prison medical service in that prison. However, as a result of our considerable experience of treating or representing hundreds of opiate dependent subjects as patients or clients we are concerned that conditions seem to be ideal for the rapid but unrecognised transmission of HIV throughout the whole of the British prison system.

We sympathise with the difficult working conditions and stressful professional relationships for doctors who work with prisoners. We also have come across individual instances of sympathetic provision of care by prison medical officers. However, more frequently described to us by former patients are feelings of injustice and antagonism towards the prison medical services. It is our view that this largely attributable to the consequences of the service enjoying the monopoly of clinical power within prisons. As it is the guardian of the prison public health and sole provider of primary care and of most secondary care, the health care service for prisoners must, in our view, assume much of the responsibility for this crisis.